Mr. Lanting, a member of South Holland Protestant Reformed Church, is a practicing attorney.
“So when artificial nourishment provides no detectable benefits but does cause various sorts of hardships, one can argue that withdrawing it signals covenantal concern, not abandonment. We conclude, then, that withdrawing artificial feeding should sometimes be permitted and even recommended.”
Christian Faith, Health, & Medical Practice, Bouma et al.
The phone call came about 4:00 P.M. on a melancholy March afternoon as I was concluding a routine day at my office. “We’re calling an emergency meeting of the Board’s Ethics Committee at 5:00 P.M. today at our South building,” said the Rest Haven’s Executive Director. “Can you be there? Dr. DeJong is going to chair the meeting.”
Later, hurrying across the wet asphalt parking lot in the light drizzle toward the offices on the west wing of Rest Haven convalescent home, I had a premonition that this was to be a difficult meeting. The resident director introduced our Ethics Committee to the family—two middle-aged daughters, one from Iowa and the other from Indiana. They had demanded this meeting with the Board members, the resident director explained, because Rest Haven was failing to comply with the family’s demands to terminate medical treatment for their 83 year old mother who was suffering from advanced stage Alzheimer’s disease.
The family explained that their mother, a total care patient for almost ten years, had recently contracted a mild pneumonia (often caused by aspirating food) and was also temporarily unable to swallow food or water. The director had contacted a doctor who prescribed penicillin to combat the pneumonia and a nasal feeding tube to provide nutrition and hydration. With angry tears, the irate daughters implored our Ethics Committee to overrule the resident director and comply with their written request to terminate the penicillin and withhold all nutrition and hydration. It was God’s will, they insisted, that their mother die from the natural consequences of advanced Alzheimers, even if this entailed malnutrition and dehydration. “She is not dying because she’s starving,” said the Iowa daughter, “but she’s starving because she’s dying.” Also their mother’s “quality of life” was minimal, the daughters reminded us, since she had been incoherent, unresponsive, and totally bedridden for several years. To prolong her life now by “artificial” feeding and medication, they argued, would be interfering with God’s will that she die in this way.
The resident director calmly responded that since the penicillin medication and the tube feeding were “ordinary” and not “extraordinary” or “heroic” means, such rudimentary forms of medical treatment were the minimal moral obligation of a Christian long-term care facility.
After a two-hour discussion, the resident’s family was excused from the meeting and our committee faced the profoundly difficult ethical, religious, and legal question: Do we advise the resident director to comply with the family’s wishes to withhold penicillin, food, and water from this dying woman, or is the nursing home ethically compelled to provide “ordinary” care to all residents, including nutrition and hydration?
Ethics, medicine, and law converge
In contrast to the early, 1900s when two-thirds of the people in the United States died before age fifty in the family home setting, nowadays 65% of an ever aging population dies in medical institutions and nursing homes. Advancing medical technology, rapidly changing laws regarding patient’s rights (including the so-called “right to die” and “advanced directives” legislation), and diverse religious ethical views have made death and dying issues extremely problematic for dying patients, their families, and Christian nursing homes and health care providers.
The perennial controversy over withdrawing “ordinary” medical care (see box) has recently focused on the controversial practice of withholding food and water from a dying patient unable to swallow. Evangelical Christians are now divided over whether the termination of nutrition and hydration is tantamount to euthanasia, a practice condemned by Reformed ethicists.
But in their recent book, Christian Faith, Health, and Medical Practice, the authors (fellows at Calvin College’s Calvin Center for Christian Scholarship) conclude that withholding food and water can “sometimes” be “recommended” (see lead quote above), but readily admit this view has “possibilities for abuse”:
We conclude, then, that withdrawing artificial feeding should sometimes be permitted and even recommended. Our toleration for and cooperation with it, however, require the satisfaction of two important provisions: (1) safeguards must ensure that the welfare of the terminally ill or permanently unconscious patient is the primary consideration, and (2) appropriate means must be used to minimize the negative psychological side effects. For some, however, these provisions may seem infeasible. The possibilities for abuse and the powerful symbolic nature of withdrawing what is universally accepted as necessary to sustain physical life make us respect the stand of those who find it morally impermissible to cooperate in acts of withdrawing artificial means of providing nourishment.
The author’s concern about the dangerous implications of withholding food and water is real. A recent issue of the National Right to Life News reports the case of Marjorie Nighbert in northern Florida. In 1992 Nighbert signed a power of attorney for health care (see box), giving her brother complete control over her medical decisions, and allegedly instructed him she did not want a feeding tube should she be unable to swallow.
Early in 1995 she suffered a stroke and was admitted to a convalescent home. Because her doctor and family feared she would aspirate food, they withheld all nutrition rather than place her on a feeding tube. Two weeks after one nurse had been disciplined for giving her a little milk, Nighbert touched another nurse on the arm and asked: “Would you please give me a little something to eat?” After this nurse reported the “starvation” to the authorities, a Florida court ordered that she be placed on a feeding tube until a full hearing could be held. But soon thereafter at the hearing, the Judge ordered that her feeding tube be removed. He ruled that because of her stroke she was not competent to revoke her 1992 power of attorney given her brother, and her pleas for food were to be ignored.
Is tube feeding “extraordinary” medical treatment?
Many states now treat withholding of food and water no differently than withholding medical treatment. In fact, in a 1987 North Dakota case spoon-feeding was held to be beyond normal medical procedure. And reportedly many states permit withdrawal of nutrition and hydration if a patient cannot communicate and has not previously made his wishes known.
Death and dying issues often turn on terminology open to vigorous debate. But a crucial distinction nearly universally accepted is the difference between “ordinary” and “extraordinary” means (see box). It is generally agreed by ethicists that “ordinary means” are morally obligatory, while “extraordinary” means of medical treatment are not.
But in the context of modern medical technology, how do we employ that classical distinction today? Are respirators ordinary or “extraordinary” means? What about antibiotics and penicillin? What about nasogastric tube feeding or IV hydration?
Biblical perspective on death and dying
But because contemporary medical science has provided us with a seemingly endless and bewildering array of therapeutic instrumentalities, when does the Reformed Christian family terminate treatment of the dying loved one? John Frame in his excellent book,Medical Ethics, Principles, Persons and Problems(Presbyterian and Reformed, 1988), notes that “medicine’s death-resisting instincts must be tempered by ones that are in some sense death-accepting.” He reminds the reader that Christians know there is a time to be born and a time to die (Ecclesiastes 3:3). Moreover, the believer knows that death is not final; it holds no ultimate terrors; it is the doorway to eternal life.
Frame then suggests the following guideline for termination of treatment for the dying patient (which I shall call Principle One):
Principle One: When a disease has advanced to the point where no known therapy exists and death is imminent (within two weeks without intensive medical support) despite the means used, then forms of treatment that would secure only a precarious and burdensome prolongation of life may be discontinued or withheld. In truly terminal cases the use of certain means would not be therapeutic, but only prolong an irreversible process of dying. By “terminal illness” is meant an incurable, irreversible, and hopeless illness.
To this general principle must be added the two additional death and dying guidelines that have been suggested by certain Roman Catholic scholars and ethicists:
Principle Two: Nutrition and hydration may not be withdrawn or withheld from a patient if to do so would result in death from starvation or dehydration rather than from the underlying terminal illness or injury unless the provision of such would cause complications or exaggerate the compromising conditions of the terminal illness. Principle Three: A dying person must always be afforded palliative care including pain management, normal nursing care, and the Christian love, compassion, and understanding needed when death is imminent.
It is suggested that these broad guidelines may be helpful for Reformed Christian families confronting death and dying issues in today’s culture where the secular principles of medical economics, so-called “quality of life” issues, and euthanasia considerations are gaining frightening influence.
Power of Attorney for Health Care: a legal document authorizing a person (an agent) to make health care decisions on behalf of another (the principal}. The Power of Attorney for Health Care (POAHC) has many advantages over a Living Will, another type of “advanced directive.”
Living Will: a legal document stating, that the declarant does not want death-delaying medical procedures used if the declarant develops a terminal condition. A “terminal condition” is often defined as an incurable and irreversible illness such that death is imminent.
Health Care Surrogate: many states now have a Health Care Surrogate Act under which a voluntary individual, called a “surrogate,” may make life-sustaining treatment decisions for an incompetent terminally ill patient who has no Living Will or POAHC, The law usually provides the surrogate may be a spouse, adult, children, parents, siblings, etc.
Ordinary and extraordinary means: Ordinary means are all those medicines, treatments, and operations which offer reasonable hope of benefit add which can be obtained and used without excessive expense, pain, or other inconvenience. Extraordinary or heroic means are medical treatments which are not ordinary. Most ethicists concur that ordinary means are often morally obligatory even in the treatment of the, terminally ill.